Wellness Center Release and Waiver Form

Upon submitting this form, I make application for myself and/or child to participate in the Howard County General Hospital Wellness Center event(s) checked below. In consideration for being accepted and permitted to participate in this program, I do hereby, both for myself, my heirs, administrators, executors, and assigns, grant unto the Howard County General Hospital, Inc., and its servants, agents, employees, and any other representatives, a complete release and discharge of and from any and all claims and demands of any nature whatsoever, which I may now have or which I may have in the future resulting from or pertaining or incidental to my acceptance and participation of myself/child in said program, including, without limitation or restriction, any and all claims and demands for illness, injury, or occurrence whatsoever and I do hereby expressly waive and renounce any and all such claims and demands.

Furthermore, in consideration of myself/child being accepted and permitted to participate in said Program, I do hereby voluntarily and knowingly assume any and all risks of injury or damage, which he/she might suffer as a result of my participation in said Program.

I further declare that I have read the foregoing carefully and am fully aware of all the circumstances and ramifications connected with the subject of this Release, Discharge, Waiver, Assumption, and Renunciation.

Please check all applicable classes:*

Home Sweet Home

Kids Self-Defense

Self-Defense for Young Women

Women's Self-Defense

Other (please specify in the space below)

Name(s) and Contact Information:

Name of Parent, Legal Guardian, or Adult Participant

Name(s) of Child(ren):

Daytime Telephone:

Evening Telephone:

E-mail Address:*

By clicking "Submit" below, I attest that I am the aforementioned Parent, Legal Guardian, or Adult Participant and I agree to the terms stated above.